267 Exam 2 Review
The nurse notes that the physician has documented a diagnosis of presbycusis on the client's chart. The nurse plans care knowing that the condition is:
A sensorineural hearing loss that occurs with aging
The function of the ear is for A. Hearing and equilibrium B. Equilibrium and perforations C. Perforations and balance D. Balance and equilibrium
A. Hearing and Equilibrium
When assessing a patient, the nurse notes a brownish ridge along the gum line. This finding would be considered normal in a patient from what background?
African American
A new nurse on the long-term care unit is learning how to assess a patient's risk for skin breakdown. What would be the most likely instrument this nurse would use?
Braden Scale
When performing an abdominal assessment, what is the correct sequence?
Inspection, auscultation, percussion, palpation
When doing an assessment of the spine of an older adult, you can expect to see which variation?
Kyphosis
A 29 year-old woman was in a motor vehicle crash (MVC) and suffered a complete spinal cord injury to L3. The nurse assess the patient for loss of motor function in the
Legs
The nurse has assessed the nose and documents expected findings as
Nose symmetrical and midline
The nurses assesses the response of the eye to light and documents normal findings as
PERRLA
Older adults often have trouble with constipation. What might cause this?
Slowing of peristalsis
Use of the Glasgow Coma Score (GCS) provides relatively objective assessment of level of consciousness (LOC). The three functions assessed are:
Verbal response, eye opening, and motor response
A 64 year-old man has had a stroke in the right parietal area of the brain. The nurse expects to note which of the following?
Weakness in the left arm
The ABCDs of melanoma identification include all of the following except: a) Asymmetry: one half does not match the other half b) Birthmark: recently changed in appearance c) Color: pigmentation is not uniform; there may be shades of tan, brown, and black as well as red, white, and blue. d) Diameter: greater than 6mm
b) Birthmark: recently changed in appearance
When assessing hydration, the nurse will pinch a fold of skin
just below the midpoint of one of the clavicles and allow the skin to recoil to normal
A patient in a nursing home was admitted with a diagnosis of dementia. He started a fire because he was cooking and home and forgot that he left a pan on the stove. The nursing diagnosis that is highest priority is
risk for injury
